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Intravenous access - Peripheral

  • Background

    • 'Needles' are often the most feared painful procedure in children.
    • Always justify the need for the procedure.
    • Combine with blood sampling if needed.
    • Explain the procedure to the child and parents and obtain verbal consent.

    Selection of Intravenous ( IV ) access

    The following guidelines should be considered when referring patient for IV access:

    Duration IV access required   

    Selection of catheter

    < 7 days  Peripheral IV access
    7-14 days or
    failed peripheral IV attempts 
    PICC (peripherally inserted central catheter) or Percutaneous CVAD
    > 14 days   PICC or resite percutaneous CVAD or consider Surgical Line 
    Long term (> 30 days) Surgical CVAD (Hickman/Broviac or Ports)

    Preparation

    The patient

    Infants <3 months:

    • Oral sucrose with a pacifier should be used (see Analgesia guideline) or encourage mother to feed infant during procedure.
    • Give parent or carer option to hold infant during procedure & employ multisensory stimulation

    Older infants & children:

    • Apply topical anaesthetic creams in advance of procedure whenever possible:
      • AnGel™: 45 minutes
      • EMLA™: 60 minutes
    • Explain what you are doing -needs discussion
    • Use Play Therapy, distraction, relaxation and other coping skills, see Comfort Kids techniques
    • Consider nitrous oxide for anxious children
    Setting & equipment
    • Whenever possible, procedures should be performed AWAY from the bedside (i.e. in treatment rooms)
    • Get helpers - you will need at least one other staff-member
    • Adequate lighting

    Have equipment ready before the child enters the room:

    • Dressing pack
    • Skin preparation: alcoholic chlorhexidine
    • IV cannula
    • Sterile syringe & blood tubes (for blood)
    • Syringe - with normal saline
    • 3-way tap connector and tubing, primed with N-saline
    • Sterile IV dressing (eg. Tegaderm™)
    • Taping, splint &  Crepe bandage
     Yourself 

    Procedure

    Sites

    • Look carefully with a torniquet for the most suitable vein & remember that in paediatric patients the best vein may not necessarily be palpable.
    • Dorsum of the non-dominant hand is preferred - the vein running between the 4th and 5th metacarpals is most frequently used.
    • In addition to the usual sites in adults, commonly used sites in children include the volar aspect of the forearm, dorsum of the foot & the great saphenous vein at ankle.
    • Consider practicalities of splinting (e.g. elbow, foot in a mobile child).
    • Scalp veins should only be used by more experienced doctors (shaved scalp hair re-grows very slowly).

    Technique

    Holding

    • Ask the assistant to stabilise limb by holding joint above & joint below if necessary.
    • If applying tourniquet, be careful of pinching skin or compressing artery.
    • In infants when accessing the hand, grasp as shown; this achieves both immobilisation and tourniquet ( Fig 1)

    Inserting the cannula

    • Decontaminate skin with alcohol wipe or alcoholic chlorhexidine 0.5% & leave to dry. Use 'no-touch' technique for insertion after decontamination.
    • Insert just distal to and along the line of the vein
    • Angle at 10-15° ( Fig 2)
    • Advance needle & cannula slowly
    • A 'flash back' of blood may not occur for small veins.
    • Once in vein, advance the needle & cannula SLOWLY a further 1-2mm along the line of the vein before advancing cannula off needle.
    • Secure the hub of the cannula at the skin entry point either by holding it down or asking the assistant to place tape across.
     shallow angle.jpg  
    Figure 1: holding an infant's hand  Figure 2: shallow angle of insertion  

    Taking blood samples

    • For 24G cannulae, it is often easier to let blood drip passively into collection bottles (Fig 3)
    • When taking blood for culture or gas from small cannulae, aspirate blood from the hub of the cannula using a blunt 'drawing up' needle and syringe (Fig 4)
    • For larger cannulae, a syringe can be used to aspirate blood.
    shallow angle.jpg shallow angle.jpg  
     Figure 3: passive blood collection for infants

    Fig 4: aspirating blood for culture or gas

     

    Strapping

    • Connect the saline-filled 3-way connector to the end of the cannula by screwing it firmly on.Flush the connector tubing with more saline to confirm intravenous placement.
    • In younger children use inverted cross-over straps and another tape over the top (Fig 5)
    • Consider placing a small piece of cotton wool ball or gauze underneath the hub of the cannula to prevent pressure areas (Fig 5)
    • Place an adhesive clear plastic dressing on top (Fig 6)
    • Tapes should secure the limb proximal and distal to the cannula (keeping thumb free) but not too tightly (Fig 7)
    • Wrap the whole distal extremity in Tubular-Fast (Surgifix).. In very young children, give consideration to bandaging the other hand as well to prevent them from removing the cannula.
    shallow angle.jpg shallow angle.jpg  
    Fig 5: pad under cannula to prevent pressure areas. IV site should remain visible   Fig 6: secure with tegadermTM so that IV site is visible  

    shallow angle.jpg

    Fig 7: Strap so that joint is immobilised, but avoiding tapes being too tight

    Post-Procedure Care

    • Running a 'drug line' (3-5ml/hr of N Saline) through the cannula may keep it patent for a longer period of time.
    • Inspect insertion site for complications (tenderness, blockage, inflammation, discharge) hourly - check the other hand if it has also been bandaged.. 
    • Unless complications develop, the peripheral IV should remain insitu until IV treatment complete.

    Trans-illumination

    • Application a COLD light directly to the skin in a darkened room can be helpful in finding veins in neonates and infants.
    • Only cold lights (usually fiber-optic sources) should be used. Normal torches can burn the skin and should never be used.
    • Trans-illumination adds a layer of complexity to IV insertion as the operator has to hold a light to the skin, position the site and insert the cannula.

    Unsuccessful insertion

    • Only 2 attempts should be made to insert a cannula and multiple(s) unsuccessful attempts should be avoided.
    • See flow chart
    iv insertion


    Other resources

    Peripheral Intravenous device management guideline

    RCH Comfort kids resources

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